Provider Demographics
NPI:1255713079
Name:LAZAR, INNA (OD)
Entity type:Individual
Prefix:
First Name:INNA
Middle Name:
Last Name:LAZAR
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 ARCADIA ROAD
Mailing Address - Street 2:SUITE 18
Mailing Address - City:OLD GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06611
Mailing Address - Country:US
Mailing Address - Phone:203-698-5049
Mailing Address - Fax:
Practice Address - Street 1:13 ARCADIA RD STE 18
Practice Address - Street 2:
Practice Address - City:OLD GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06870-1742
Practice Address - Country:US
Practice Address - Phone:203-698-5049
Practice Address - Fax:844-364-2562
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-29
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2947152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1255713079Medicaid